Acute Coronary Syndromes Flashcards
ACS: Signs/Sx
-Chest pain (pressure/squeezing)
>10 min, dyspnea, diaphoresis, radiate to arms/back/neck/jaw
-Pts with SL NTG RX should use 1 dose every 5 minutes for up to 3 doses to relieve chest pain
-If chest pain is not improved or is worse 5 minutes after the
first dose, they should call 911 immediately
UA vs NSTEMI vs STEMI
UA: negative cardiac enzymes, no ECG changes or ST dep/T waves, partial blockade
NSTEMI: positive cardiac enzymes, no ECG changes or ST dep/T waves, partial blockade
STEMI: positive cardiac enzymes, ST elevation, complete blockade
PCI
-Inflating balloon inside coronary artery to widen it and improve blood flow (revascularization procedure)
NST-ACS: PCI or med mgmt
STEMI: PCI or fibrolysis
-PCI preferred, if it can be done within 90 min (door-to-balloon) or within 120 min (from first medical contact)
-If PCI not possible within 120 min, fibrinolytic tx within 30 min (door-to-needle)
Drug Tx
Morphine
Oxygen
Nitrates
Aspirin
G PIIb/IIIa antagonists
Anticoagulatns
P2Y12 inhibitors
Beta-blockers
ACE inhibitors
-NSTE-ACS: MONA-GAP-BA +/- PCI
-STEMI: MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)
Morphine
-Pain relief
-Not for routine use (shown to diminish AP effects), reserve for pts with unaccepbble chest discomfort
-Dose: 2-5 mg IV q 5-30 min PRN
Oxygen
Oxygen Sat <90% or respiratory distress
Nitrates
SL NTG 0.4 mg q5 min x3 doses (if not already given)
If sx persist: IV NTG
-Do not use IV NTG if SBP < 90, HR < 50, or RIGHT ventricular infarction
-CI WITH PDE5 inhibitors
Aspirin
-No enteric coated: CHEWABLE (fast)
-Dose: 162-325 mg ASAP
-Maintenance: 75-100 mg indefinitely
Give within 24 hours of ACS
-BB: B1 selective agent (AMEBBA)
*If has HFrEF: biso, meto, carve
-ACEi: in all pts LVEF < 40%, DIA, CKD, HTN
*ARB if ACEi is intolerable
Meds To Avoid In Acute Setting
-NSAIDs
-IR Nifedipine
Clopidogrel (Plavix)
LD 300-600 mg (600 mg for PCI)
MD 75 mg daily
Prodrug, CYP2C19 PM
CI: serious active bleeding
-Stop 5 days prior to elective surgery
DDI: don’t use with omeprazole/eso
AE: thrombotic thrombocytopenia purpura (TTP)
Prasugrel (Effient)
LD 60 mg (max 1 hour after PCI)
MD 10 mg daily with asa
Protect from light, OG CONTAINER
BBW: bleeding
Do not initiate if CABG
-Stop 7 days prior to elective surgery
CI: serious active bleeding, TIA/stroke hx
AE: TTP, bleeding risk (higher than plavix)
Ticagrelor (Brillinta)
LD 180 mg
MD 90 mg BID x1 year, 60 mg BID
BBW: bleeding
-Max MD 100 mg ASA (ASA can decrease effectiveness of tica)
Do not initiate if CABG
-Stop 5 days prior to any surgery
CI: serious bleeding
AE: TTP, dyspnea
Cangrelor (Kengreal)
Injection
Only indicated as an adjunct to PCI in pts who are P2Y12 inhibitor naive and are not receiving a GPllb/llla inhibitor
P2Y12 Inhibitor DDIs
Clopidogrel, Ticagrelor, Prasugrel, Cangrelor
Other meds that increase bleeding risk
-Warfarin, NSAIDs, SSRI, SNRI
Clopidogrel: CI with omeprazole/eso
Glycoprotein IIb/IIIa RA
Eptifibatide, Tirofiban, Abciximab
AE: bleeding, thrombocytopenia
CI: PLT <100k, active bleeding, uncontrolled HTN, recent major surgery/trauma, stroke within 30d (eptif)
(SESH PB)
Vorapaxar (Zontivity)
Indicated in patients with a history of MI or peripheral arterial disease (PAD) to reduce thrombotic events
Fibrinolytics: Overview
Alteplase, Tenecteplase
Cause fibrinolysis (break up clots)
Used only for STEMI
-Given within 30 min (door-to-needle)
Alteplase (Activase): Dosing
> 67 kg: 100 mg over 1.5 hours:
-15 mg bolus
-50 mg over 30 min
-35 mg over 1 hour
67 or < kg:
-15 mg bolus
-0.75 mg/kg (max 50 mg) over 30 min
-0.5 mg/kg (max 35 mg) over 1 hour
-Max total 100 mg
Tenecteplase (TNKase): Dosing
Single IV bolus dose:
< 60 kg: 30 mg
60-69 kg: 35 mg
70-79 kg: 40 mg
80-89 kg: 45 mg
90 kg: 50mg
Alteplase/Tenecteplase: CI/AE
CI: HIS BI
-active internal bleeding
-hx of recent stroke
-prior ICH
-recent intracranial/intraspinal surgery/trauma
-severe uncontrolled HTN (no response to tx)
AE: bleeding (ICH)
Monitor: Hgb, Hct, bleeding
Secondary Prevention of ACS
- Aspirin (indefinitely)
- DAPT:
-MM: Tica/Clop + ASA for at least 12 months
-PCI: Tica/Clop/Pras + ASA for at least 12 months - NTG
- BB x3 years (indefinitely if HF/HTN)
- ACEi (indefinitely if LVEF < 40, HTN, DIA, CKD, MI)
- Aldosterones (SE, unless CI with Scr/K)
- Statins
Other Considerations
-Pain: naproxen has lowest CV risk
-ACS + AF: triple antithrombitic therapy can be used (shortest time possible, clop preferred for triple, PPIs for GI bleed hx)
-Lifestyle modifications
